Immaculatemarycenter for Rehabilitation&healthcare

Inspectors wroteBased on interviews with resident and staff and review of clinical records and facility documentation determined the facility did not ensure a resident's dignity was maintained during care for one of 35 resident records reviewed (Resident R85).

Inspectors wroteBased on review of facility policy, review of facility documentation, review of clinical records, and staff interviews, it was determined that the facility failed to ensure one resident received a gradual dose reduction of a psychotropic medication for one of five residents reviewed (Resident R193). Findings Include: Review of facility policy Psychotropic Medications revised September 2025 revealed psychotropic medications will be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction and re-review. [...]

Inspectors wroteBased on staff interviews and review of clinical records, it determined the facility failed to develop a comprehensive care plan related to diagnoses Diabetes Mellitus and urinary catheter for two of 35 resident records reviewed (Resident R15).

Inspectors wroteBased on review of clinical records, review of facility policy and interview with staff, it was determined that facility did not ensure that residents received treatment and care in accordance with professional standards of practice related to abnormal laboratory values for one of 35 residents reviewed (Resident R8)

Inspectors wroteBased on observation, review of clinical record, review of facility policy, interview with staff and residents, it was determined that the facility failed to ensure that a urine bags (nephrostomy bag) were draining by gravity for one of 35 residents reviewed. (Resident R17)

Inspectors wroteBased on review of facility policy, review of clinical records, and staff and resident interviews, it was determined that the facility failed to identify, implement, monitor, and modify interventions to maintain acceptable parameters of nutrition for two of five residents reviewed for nutrition (Resident R173 and R282).

Inspectors wroteBased on observations, review of facility policies and procedures, and interview with staff, it was determined facility did not ensure that drugs and biologicals were stored according to professional standards of practice for one of two medication storage rooms reviewed on 4th floor unit. (medication storage room [ROOM NUMBER] South)

Inspectors wroteBased on review of facility policy, review of clinical records, and staff interviews, it was determined that the facility failed to ensure laboratory values were timely reviewed for one of 35 residents reviewed (Resident R215). Findings Include: Review of facility policy Diagnostic & Lab Testing dated March 2020 revealed the physician will identify and order lab testing based on diagnostic and monitoring needs of a resident. Continued review of facility policy revealed a nurse will review lab results and communicate results to a physician who will review and be prepared to discuss. [...]

Inspectors wroteBased on review of facility documentation, review of clinical records, observations, and interviews with staff and residents it was determined that the facility failed to ensure residents received modified diets consistent with assessed needs for one of 35 residents reviewed (Resident R215). Findings Include: Review of facility diet manual, dated 2023, revealed pureed foods are eaten and swallowed with minimal chewing and minimal jaw movement. Foods are pureed, homogenous, and smooth; and have pudding-like consistency. [...]

Inspectors wroteBased on review of clinical record, facility policies, facility documentation, and interviews with staff, it was determined the facility failed to provide adequate supervision for one of 13 residents reviewed (Resident R1). This failure resulted in Resident R1 exiting the third-floor lockdown unit, accessing the elevator to the lobby, and walking out the front entrance of the facility. Resident R1 was located approximately two hours later at a family members residence, approximately 1.2 miles away from the facility. Resident R1 accessed a busy traffic area. This failure placed the resident at high risk for injury and was identified as an Immediate Jeopardy situation. (Resident R1)

Inspectors wroteBased on review of job descriptions, facility documentation, and interviews with staff, it was determined that the Nursing Home Administrator and Director of Nursing failed to effectively manage the facility to ensure that adequate supervisor was provided to one of 13 residents reviewed (Resident R1). This failure resulted in Resident R1 exiting the third floor locked down unit via elevator and walking out the front entrance of the facility. Resident R1 was located approximately two hours after the resident exited the facility approximately 1.2 miles away from the facility. Accessing high traffic areas and busy intersections. This failure placed the resident at high risk for injury and was identified as an Immediate Jeopardy of past non-compliance. (Resident R1)

Inspectors wroteBased on clinical record review and interview with staff, it was determined that the facility failed to ensure that an elopement risk assessment was accurate for one of 13 residents reviewed (Resident R1).

Inspectors wroteBased on the review of clinical records, podiatry consults reports and interviews with staff, it was determined that the facility failed to implement podiatry recommendation for wound care and promote wound healing for one of five residents reviewed. (Resident R1)Findings Include:According to National Library of Medicine Chronic wounds often occur in patients with diabetes mellitus due to the impairment of wound healing. Impaired healing in diabetes is the result of a complex pathophysiology involving vascular, neuropathic, immune, and biochemical components. Hyperglycemia correlates with stiffer blood vessels which cause slower circulation and microvascular dysfunction, causing reduced tissue oxygenation. Blood vessel alterations observed in diabetic patients also account for reduced leukocyte migration into the wound, which becomes more vulnerable to infections. [...]

Inspectors wroteBased on the review of clinical records, observations, and interviews with resident representative and staff, it was revealed that the facility failed to provide appropriate services to promote and maintain hearing abilities for one of five residents reviewed. (Resident R3)Findings Include:Review of Resident R3's MDS (Minimum Data Set-Assessment of resident care needs) dated February 28, revealed that resident's ability to hear had moderate difficulty and Resident R3 was using a hearing aide. Review of Resident R3's MDS (Minimum Data Set-Assessment of resident care needs) dated February 28, revealed that resident's ability to hear had moderate difficulty and Resident R3 was using a hearing aide. Interview with Resident R2's representative on September 15, 2025, at 10.50 a.m. revealed that the resident had difficulty hearing and she was missing her hearing aid. [...]

Inspectors wroteBased on clinical record review and staff interviews, the facility failed to ensure that a physician assessment was completed and that changes in medical status were addressed in accordance with professional standards of practice for diabetic management to promote wound healing for one of five residents reviewed (Resident R1). Findings Include:According to the National Library of Medicine, Chronic wounds often occur in patients with diabetes mellitus due to the impairment of wound healing. Impaired healing in diabetes is the result of a complex pathophysiology involving vascular, neuropathic, immune, and biochemical components. Hyperglycemia correlates with stiffer blood vessels which cause slower circulation and microvascular dysfunction, resulting in reduced tissue oxygenation. [...]

Inspectors wroteFindings Include:Review of facility policy Enhanced Barrier Precautions dated September 2024 revealed that Enhanced barrier precautions (EBP) utilizes targeted gown and glove use during high-contact resident care activities to reduce the transmission of MDRO's(Multi drug Resistant organisms). Examples of high contact resident care activities requiring gown and gloves for EBP include but are not limited to Dressing, Wound care: any skin opening requiring a dressing. According to CDC (Centers for Disease Control and Prevention) guidelines Infection Control Assessment and Response (ICAR) Tool for General Infection Prevention and Control (IPC) Across Settings revealed that Wound care supplies such as dressing materials and equipment should be selected and gathered prior to entering the patient/resident care area to avoid accessing the supply cart/clean storage area during the procedure. [...]

Inspectors wroteBased on review of clinical record, facility documentation, and interviews with staff, it was determined that the facility failed to report an injury of unknown origin to the local State Survey Agency as required for one of four resident records reviewed (Resident R1).

Inspectors wroteBased on observation and interview with staff, it was determined that facility did not ensure to provide a safe, clean, sanitary and homelike environment for five of 51 rooms observed (Room#'s 200-B, 207-B, 209-B, 210-B, 425-B)

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to refer a resident with a newly diagnosed mental disorder for level II of the PASRR (Pennsylvania Pre-admission Screening Resident Review) or three of three residents reviewed (Residents R119, R174, and R184).

Inspectors wroteBased on observations of care and services, interviews with staff, reviews of clinical records and policy and procedures, it was determined that the facility failed to develop a comprehensive care plan for oxygen therapy and antipsychotic medication for two out of 35 residents reviewed. (Resident R41 and R190)

Inspectors wroteBased on observations, interviews with staff, and a review of facility procedures, it was determined that the facility failed to store food in accordance with professional standards for food service safety. Facility Policy: The review of the facility's policy titled Food Storage, dated March 2020 revealed Foods shall be stored in a manner that complies with safe food handling practices. Under fourth sentence All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date). On April 14, 2025, at 9:23 a.m., a kitchen tour was conducted with the Dietary Supervisor, Employee E10. During the tour, it was observed that the preparation table contained various spices-such as ground cinnamon, chicken herb, Italian seasoning, and poultry seasoning-that were opened and not dated. [...]

Inspectors wroteBased on observations and an interview with staff, it was determined that the facility did not ensure that garbage and refuse was disposed of properly.

Inspectors wroteBased on observation, review of facility policy and procedure and interviews with staff, it was determined that the facility failed to maintain an effective infection control program related with appropriate cleaning techniques for medical equipment, on two of the four Medication Administration Reviews; (R106, R96) and Enhanced Barrier Precautions for three of four residents during wound treatment (Residents R96, R113, and R539).

Inspectors wroteBased on observation and review of facility policy, it was determined facility did not ensure dignity for one of two residents during wound care treatment (Resident R207)

Inspectors wroteBased on review of the facility policies and procedures, review of clinical records, and interview with staff, it was determined that the facility failed to implement treatment and services for incontinence management for one of 24 residents reviewed (Resident R88).

Inspectors wroteBased on a review of clinical records and facility policies and procedures, observations of care and services, and interviews with staff, it was determined that the facility failed to consistently provide respiratory care and supplemental oxygen as ordered by the physician for two of 35 residents reviewed. (Resident R41 and R57).

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to develop and implement an individualized person-centered care plan to address a resident's dementia care needs for one of 35 residents reviewed (Resident R169). Findings Include: Review of the admission sheet of Resident R169, revealed that Resident R169 was admitted to the facility on [DATE], with the diagnosis of Dementia (Dementia is not a specific disease but is rather a general term for the impaired ability to remember think, or make decisions that interferes with doing everyday activities). Review the care plan date March 13, 2025, revealed that of Resident 169's care plan revealed no care plan with measurable goals and interventions to address the care and treatment need related with dementia care of Resident R169. [...]

Inspectors wroteBased on observations, clinical record review, and interviews with residents and staff, it was determined that the facility failed to maintain personal dignity for five of five residents observed (Resident R1, R2, R3, R4, R5).

Inspectors wroteBased on clinical records and staff interviews, it was determined that the facility failed to offer and or provide the influenza and pneumococcal immunization for 10 of ten residents reviewed. (Resident R 15, R36, R39. R 73, R110, R111, R190, R204, R228, R231).

Inspectors wroteBased on observations, interviews and the review of clinical record, it was determined that the facility failed to ensure that 1 out of 37 residents was assessed to ensure that it was clinically appropriate to self-administer medication (Resident R606).

Inspectors wroteBased on interviews and review of clinical records, it was determined that the facility failed to ensure that written notice, including the reason for the room change was provided to the resident and/his or her responsible party prior to the room change for 1 out of 37 residents reviewed (Resident R609).

Inspectors wroteBased on review of facility policy and review clinical records it was determined that the facility failed to ensure that the physician was notified of a resident's refusal to take prescribed medications for one of 46 residents reviewed (Resident R108). Findings Include: Review of the facility policy titled Administering Medications, effective March 2020, states medications shall be administered in a safe and timely manner, and as prescribed. [...]

Inspectors wroteBased on review of facility policy, review of clinical records, resident interviews, and staff interviews, it was determined the facility failed to ensure that resident care plans were reviewed and revised to reflect the residents' status and care needs related to communication and aggressive behavior for two of eights residents reviewed. (Resident R507 and R205)

Inspectors wroteBased on interviews and the review of clinical records, it was determined that the facility failed to maintain acceptable parameters of nutritional status related to a resident's recorded weights for 1 out of 37 residents (Resident R112).

Inspectors wroteBased on review of facility policies and clinical records and interviews with residents and staff, it was determined that the facility failed to ensure that pain management was provided that was consistent with professional standards of practice, for one of 37 residents reviewed (R71).

Inspectors wroteBased on staff interviews and the review of clinical records, it was determined that the facility failed to maintain complete and accurate records related to dialysis communication for one of 37 dialysis residents reviewed (Resident R71).

Inspectors wroteBased on interviews and the review of clinical records it was determined that that facility failed to ensure that behavioral health services were provided to 1 out of 37 residents who stated that she wanted to die (Resident R606).

Inspectors wroteBased on review of clinical records, facility policy and staff interview determined the facility failed to ensure one of 37 residents reviewed was free from a significant medication error (Resident R174).

Inspectors wroteBased on interviews and the review of clinical records, it was determined that the facility failed to ensure complete and accurate clinical records for 1 out of 37 records reviewed (Resident R98).

Inspectors wroteBased on review of facility policy, observations, review of clinical records, review of facility documents, and staff interviews it was determined that the facility failed to maintain an effective pest control program in the main kitchen, laundry, and one resident room. Findings Include: Review of pest control report dated February 19, 2024, revealed the kitchen is seeing roaches . a lot of roach activity behind the wall covering by the steamers . recommended a clean out. The administration would like to try conventional treatments first. Review of pest control report dated February 22, 2024, revealed the kitchen was treated for roach activity. Review of pest control report dated May 8, 2024, revealed the pest control company met with the Nursing Home Administrator, Employee E1, and the dietary manager to discuss roaches in kitchen oven. [...]

Inspectors wroteBased on observation, and staff interview, it was determined that the facility failed to provide a clean and homelike environment to on one of two nursing units (Third Floor Nursing Unit).

Inspectors wroteBased on the review of clinical records, facility documentation, facility policies, and interviews with resident and staff, it was determined that the facility failed to demonstrate evidence that a resident/resident representative grievance was promptly documented, and resolved for one of three resident records reviewed and failed to ensure that the grievance policy inlcuded all the required components. (Resident R1) Findings Include: Review of facility policy Grievance/Concern Recording and Investigation revised 09/2023 revealed Grievances/concerns filed with the facility will be investigated and actions will be taken to resolve the grievance/concerns. Policy Interpretation and Implementation: The Administrator has assigned the responsibility of investigating grievances/concerns to the department director or designee. [...]

Inspectors wroteBased on review of facility's policies, review of clinical records and staff interviews, it was determined that the facility failed to ensure that an alleged violations involving resident neglect was reported to the State Survey Agency (Department of Health) as required for two of three residents reviewed (Resident R1 and Resident R2).

Inspectors wroteBased on review of clinical records, facility policies and interviews with staff, it was determined that the facility failed to conduct a complete and thorough investigation of improper resident care for one of three residents reviewed. (Resident R2).